1790319010 NPI number — DARCI WALLER

Table of content: DARCI WALLER (NPI 1790319010)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790319010 NPI number — DARCI WALLER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WALLER
Provider First Name:
DARCI
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1790319010
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/25/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 330627
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ATLANTIC BEACH
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32233-0627
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
904-318-8041
Provider Business Mailing Address Fax Number:
866-730-7983

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3505 WATERCHASE WAY E
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JACKSONVILLE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32224-0802
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-318-8041
Provider Business Practice Location Address Fax Number:
866-730-7983
Provider Enumeration Date:
02/25/2020

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 222Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 105991900 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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